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Sugammadex Reversal of Inadvertent Maternal Neuromuscular Blockade During Intrauterine Transfusion
Abstract Number: T2C-1
Abstract Type: Case Report/Case Series
Introduction: Intrauterine transfusion (IUT) may be life-saving for severe fetal anemia due to maternal anti-D alloimmunization. Ultrasound (US) guided intravascular IUT is performed 6 times per year at our institution. Fetal paralysis using non-depolarizing neuromuscular blocking agents (NMBAs) may improve procedural safety.1 This case highlights the under recognized potential of maternal respiratory compromise from fetal neuromuscular blockade for IUT and the novel use of sugammadex as a reversal agent.
Clinical Scenario: An IUT was recommended for a healthy 70 kg, 34-year-old gravida 3 para 2 at 29 weeks’ gestation with anti-D alloimmunization and suspected fetal anemia (MCA peak systolic velocity > 1.5 multiples of the median, trace ascites and a small pericardial effusion).
With consent, IUT was performed in the ambulatory Fetal Assessment and Treatment Centre. At 14:40, after maternal vascular access and 1mg of oral lorazepam, 6mg of rocuronium (0.6ml rocuronium 10mg/ml with 0.4ml normal saline (NS)) was administered into the fetal buttock intramuscularly (IM) under continuous US guidance using a 22-gauge spinal needle. At 14:55, 5mg rocuronium IM (0.5ml with 0.5ml NS) was repeated as the fetus remained active. With continued fetal movement, a third fetal IM injection of undiluted rocuronium 0.8ml (8mg) as administered at 15:08. During injection, the fetus moved, displacing the needle, which was then immediately withdrawn.
One minute later, the patient described perioral numbness with chest and neck flushing observed. At 15:10 she was unable to move her arms and head, was involuntarily arching her back and was noted to be dyspneic and in respiratory distress. Immediately, 100% oxygen non-rebreathing facemask was placed, a crystalloid bolus was initiated and transfer commenced to the Birth Unit operating room.
Upon OR arrival (15:15), anesthesia staff began immediate 100% oxygen bag mask ventilation, placing hemodynamic monitors and crystalloid bolus. Initial vitals were: SpO2 97%, NIBP 130/68 mmHg, maternal HR of 70 bpm and FHR 130 bpm. Clinical exam revealed poor muscle tone, with worsened dyspnea and dysphonia. A GE NeuroMuscular Transmission™ monitor was placed on the adductor pollicis, with initial Train of Four (TOF) count 0/4 twitches. Sugammadex 100mg IV was administered, at 30 seconds post injection repeat TOF was 4/4 twitches with TOR ratio of 95%. Immediately dyspnea resolved, the patient vocalized feeling better and could move spontaneously. The IUT was completed, the patient was transferred the Recovery without further event, and discharged home the next day after confirming fetal wellbeing.
Conclusion: When NMBAs are administered in “out of the operating room” environments, monitoring, resuscitative equipment, reversal agents and skilled assistance should be immediately available for managing potential inadvertent maternal absorption and neuromuscular blockade.
1. AJOG. 2013;209(3):170-80.